Aggressive Surgery Research Articles

Predictive factors of surgical complications after pelvic exenteration for gynecological malignancies: a large single-institution experience.

To evaluate pre-operative predictors of early (<30 days) severe complications (grade Dindo 3+) in patients with gynecological malignancy submitted to pelvic exenteration (PE). We retrospectively analyzed 129 patients submitted to surgery at Fondazione Policlinico Gemelli between 2010 and 2019. We included patients affected by primary or recurrent/persistent cervical, endometrial, or vulvar/vaginal cancers. Post-operative complications were graded according to the Dindo classification. Logistic regression was used to analyze potential predictors of complications. We performed 63 anterior PE, 10 posterior PE, and 56 total PE. The incidence of early severe post-operative complications was 27.9% (n=36), and the early mortality rate was 2.3% (n=3). More frequent complications were related to the urinary diversion and intestinal surgery. In univariable analysis, hemoglobin ≤10 g/dL (odds ratio [OR]=4.2; 95% confidence interval [CI]=1.65-10.7; p=0.003), low albumin levels (OR=3.9; 95% CI=1.27-12.11; p=0.025), diabetes (OR=4.15; 95% CI=1.22-14.1; p=0.022), 2+ comorbidities at presentation (OR=5.18; 95% CI=1.49-17.93; p=0.012) were predictors of early severe complications. In multivariable analysis, only low hemoglobin and comorbidities at presentation were independent predictors of complications. Pelvic exenteration is an aggressive surgery characterized by a high rate of post-operative complications. Pre-operative assessment of comorbidities and patient health status are crucial to better select the right candidate for this type of surgery.

Assessing the Efficacy of Tranexamic Acid in Minimizing Perioperative Blood Loss in Ovarian Cancer Surgery: A Systematic Review of Randomized Controlled Trials and Meta-Analysis

Introduction: Ovarian cancer stands as the predominant gynecological malignancy on a global scale a global gynecological malignancy with a &gt;60% mortality rate, often necessitates aggressive surgeries like maximal cytoreduction to enhance survival. However, these procedures pose bleeding risks requiring blood transfusions. Tranexamic acid (TXA), a longestablished clotting inhibitor, offers potential solutions. Our objective is to assess TXA's safety and efficacy in minimizing perioperative bleeding during ovarian cancer surgery through a thorough literature review .

Diagnosis and management of mediastinal extragonadal germ cell tumors

SummaryExtragonadal germ cell tumors (EGCT) are rare and comprise only 2–3% of all testicular germ cell tumors. The majority of EGCT are located in the mediastinum, followed by the retroperitoneum. Although histologically similar to germ cell tumors (GCT), EGCT have distinct histological patterns which result in a biologically aggressive variant of GCT with the need for interdisciplinary care in highly specialized centers. The majority of mediastinal EGCT harbor teratoma or yolk sac tumor elements. Treatment usually consists of a combination of systemic cytotoxic therapy and aggressive postchemotherapeutic surgery. First-line treatment for extragonadal seminomas and nonseminomas consists of three and four cycles of PEB or PEI, respectively. In patients with significantly elevated markers, a personalized approach based on adequate marker decline can be used, and in poor-risk patients, first-line high-dose chemotherapy might be discussed. Postchemotherapeutic surgery remains an integral part of the multidisciplinary treatment for nonseminomatous EGCT and it is of utmost importance that all residual masses, independent of size and location, are resected completely. Residual masses in seminomatous EGCTs rarely harbor vital cancer and might be followed by serial imaging studies or FDG-PET/CT. The prognosis of nonseminomatous EGCT is poor, with 5‑year overall survival rates of 17%, 60–70%, and 90% for poor, intermediate, and excellent prognosis, respectively. Prognosis for seminomatous EGCT is excellent, with 5‑year overall survival rates of 95% and 88% for good and intermediate prognosis, respectively. Salvage chemotherapy consists of high-dose chemotherapy or targeted therapy in very selected patients.

Adenosquamous carcinoma of prostate: An entity out of the ordinary

Adenosquamous carcinoma (ASC) of the prostate is an extremely rare, aggressive histological subtype of prostate cancer. We report one such case here of a 73-year-old man with prostatic malignancy with a combination of squamous and glandular components. Immunohistochemistry with p40, AMACR and HMWCK corroborated the diagnosis of ASC. The squamous component being refractory, is better amenable to aggressive surgery, highlighting the importance of recognising this entity. Bony metastasis was not seen in this patient. Serum PSA was near normal.

Complications After Open Skull Base Surgery for Brain Tumors: A 26-Year Experience.

Open skull base surgery carries the risk of significant complications. It is important to inform patients and family members clearly of the details of these complications. This study aimed to present the numerous complications encountered with open skull base surgery for brain tumors. This report analyzed the complications experienced by patients treated with open skull base surgery by a single skull base surgeon at a single tertiary center over 26 years. A retrospective study was performed using the University of Puerto Rico Neurosurgery database to identify patients who were managed using open skull base procedures from 1995 to 2020. The neurosurgical database for each patient had been prospectively recorded. Patients with skull basetumors under the author's care during the study period were includedin the investigation. Exclusions include patients with non-tumoral conditions and non-skull base tumors and those operated using a microscopic transsphenoidal route. Patients who experienced an intraoperative or postoperative complication within 30 days of the surgery were further analyzed. In the cohort, 141 patients with brain tumors underwent open skull base surgery. The cohort had a median age of 48 (range 3-79). It consisted of 101 (71.6%) females and 40 (28.4%) males, with a female-to-male ratio of 2.5:1. The approach most frequently used was an orbitofrontal craniotomy (with or without zygomatic osteotomy) in 79 patients (56%). A petrosal approach was utilized in 26 patients (18%). Forty-six patients (33%) developed an intraoperative or postoperative complication. Twenty-four percent of the complications occurred in the 30-day postoperative period. Five patients had more than one complication. The median age of the patients who experienced a complication was 44.5 (range 22-79), with a female-to-male ratio similar to the entire cohort. Cranial nerve injury was the most frequent complication. Worsening or loss of vision in the affected eye occurred in 5.7% of the patients. A cerebrospinal fluid leak occurred in 2% of the patients. Six patients died, two of them after a massive myocardial infarction. The results of this study showed that approximately one-third of the patients undergoing open skull base surgery can develop a complication. The most frequent complication was injury to a cranial nerve. A large number of complications occurred intraoperatively. The majority of the complications in patients with tumors in the posterior fossa were associated with injury to a cranial nerve. At the middle fossa, damage to the optic nerves is a noteworthy complication. Complications at the anterior fossainvolved worsening of vision ormyocardial infarction. Less aggressive surgery near the cavernous sinus and the petroclival region may reduce complications. Understanding the complications can help counsel patients and family members.

10170-GMC-14 CRANIOPHARYNGIOMA REFRACTORY TO SURGERY AND RADIOSURGERY SUCCESSFULLY TREATED WITH ENCORAFENIB AND BINIMETINIB: A CASE REPORT

Abstract Craniopharyngioma is prone to recurrence despite aggressive surgery; repeated surgery and radiotherapy are associated with risks of pituitary insufficiency, visual inacuity and anopsia, and neurocognitive dysfunction, adversely affecting patients' activity of daily life and quality of life. In a recent clinical trial in the US, molecular targeted therapy with vemurafenib and cobimetinib has achieved excellent objective response rate in BRAF-mutant cranopharyngioma. We report a case of BRAF-mutant papillary craniopharyngioma refractory to multiple surgeries and radiosurgery that was successfully treated with encorafenib and binimetinib. Molecular targeted therapy with BRAF inhibitor and MEK inhibitor can be a treatment option for BRAF-mutant craniopharyngioma, even after multiple recurrences with surgeries and radiotherapy.

Unveiling the Immunogenicity of Ovarian Tumors as the Crucial Catalyst for Therapeutic Success

Epithelial ovarian cancer (EOC) is the most lethal gynecologic cancer. The disease is often diagnosed after wide-spread dissemination, and the standard treatment combines aggressive surgery with platinum-based chemotherapy; however, most patients experience relapse in the form of peritoneal carcinomatosis, resulting in a 5-year mortality below 45%. There is clearly a need for the development of novel treatments and cancer immunotherapies offering a different approach. Immunotherapies have demonstrated their efficacy in many types of cancers; however, only &lt;15% of EOC patients show any evidence of response. One of the main barriers behind the poor therapeutic outcome is the reduced expression of Major Histocompatibility Complexes class I (MHC I) which occurs in approximately 60% of EOC cases. This review aims to gather and enhance our current understanding of EOC, focusing on its distinct cancer characteristics related to MHC I expression, immunogenicity, antigen presentation, epithelial-to-mesenchymal transition, and various ongoing immunotherapeutic strategies designed to stimulate antitumor immunity.

Shifting Strategies in the Treatment of Pediatric Craniopharyngioma.

Craniopharyngiomas represent one of the most challenging diseases to treat. Despite their benign histology, and after many decades of surgical experience and technological advancements, there is still no clear consensus regarding the most effective management for this tumor. Due to their location and aggressive local characteristics, purely surgical approaches all too often result in unacceptable morbidity. Partial resection combined with radiation therapy results in similar control rates when compared to aggressive surgery, while also minimalizing the neuro-endocrinological morbidity. In this manuscript, we describe the historical progression of the shifting strategies in the management of pediatric craniopharyngioma. Time has also altered our expectations for outcomes, evolving from purely morbidity and mortality to simple Glasgow Outcomes Scales, now to formal neuro-psychometric and quality of life data.

Pelvic exenterations combined with cytoreductions for T4 rectal cancers with peritoneal metastasis: a safety analysis.

Pelvic exenterations and cytoreduction are individually morbid procedures with oncological validity. The combination of these simultaneously in patients with rectal cancers has not been evaluated. The present study aimed to assess the surgical and survival outcomes of the combined procedure. Retrospective, single-centre analysis of consecutive patients that underwent pelvic exenterations and cytoreductions for advanced or recurrent rectal cancers with peritoneal metastasis between 2013 and 2022. The primary outcome measure for safety was major complications (≥Grade IIIA). The threshold for considering the procedure unsafe was set at 50% for the upper confidence limit of major morbidity. Overall and recurrence-free survival were also assessed. Thirty-nine patients underwent the combined procedure that included 24 total pelvic and 15 posterior pelvic exenterations. The median age of the cohort was 35 years, 18 (46.2%) had signet ring cell cancers, and eight patients (21%) had extraperitoneal disease as well. The median PCI was 4 and CC-0 was achieved in 38 patients (97.4%). Hyperthermic intraperitoneal chemotherapy was delivered in 15 patients, and four had placement of an intraperitoneal chemo port. Major complications were experienced by 7 patients (18%; 95% confidence interval: 7.5%-33.5%). Median recurrence-free and overall survivals were 9 and 17 months, respectively. Combined pelvic exenterations and cytoreductions are safe operations in terms of morbidity. Survival, however, remains poor for this group of patients despite aggressive surgery.

838. The Role of Surgery in the Management of Invasive Fungal Rhinosinusitis Complicated by Orbitocranial Extension in the Era of Azole Antifungals

Abstract Background Orbitocranial fungal infection (OCFI) is a potentially lethal complication of fungal rhinosinusitis, historically requiring aggressive surgery despite its significant morbidity. Over the past two decades, early use of azole agents has been introduced to support amphotericin B formulations as first-line treatment followed by step down therapy with azoles, demonstrating promising outcomes. To date, there is no data regarding the contribution of surgery in the “azole era” to patients’ survival. We aimed to provide real-life data on azole treatment outcomes and the role of surgery in the current management of OCFI. Methods Data was collected retrospectively from a chart review of the four tertiary participating centers in Israel and Australia between January 1, 2009 and January 1 2020, as well as additional cases identified through a systematic literature review (Fig. 1). The study group included patients with OCFI treated with azole antifungals. Control cases were all treated with amphotericin B. The cranial and orbital involvement was staged based on imaging (Fig. 2). The extent of surgical resection was also classified to allow for inter-group comparison. Flowchart for identification, screening, eligibility, and inclusion for the systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Staging of orbitocranial fungal infection used in the study and T1 contrast-enhanced magnetic resonance images illustrating each stage I. Orbital extent: orA - periorbit, lacrimal apparatus; orB - orbital fat; orC - oculomotor muscles; orD – optic nerve, eyeball. II. Cranial extent: crA - pterygopalatine fossa, nasopharynx; crB – temporal/infratemporal fossa; crC – cavernous sinus, dura; crD – brain, spinal cord. Results There were 125 patients in the azole anti-fungal (AAF) group and 153 in the control group (Table 1). Mucorales and Aspergillus were identified in 28% and 72% of AAF cases, respectively, and 67% and 33% of control cases, respectively (p&amp;lt; 0.001). Among patients with cranial extension, 22.6% were operated on in the AAF group and 18.4% in the control group (Table 2). However, meninges and brain resection were performed only in the controls (10.5%) and never in the azole antifungals group (p=0.045). Orbital involvement required surgery in 25.9% of AAF cases and 38.6% of controls (p=0.12). Despite a more aggressive cranial involvement, azole-treated patients’ 3-year mortality was significantly lower than controls (21% vs. 52%, HR 0.27, p&amp;lt; 0.001, Fig. 4). Comparison of the study groups according to the orbitocranial fungal infection extent a. cranial extent; b. orbital extent Kaplan Meier curve on the orbitocranial fungal infection specific survival during up to 3 years of follow-up *Categorical variables are presented in n (%); **Continuous variables are represented as mean (±SD); ªAcquired immunodeficiency syndrome; bHematologic disease leading to immune compromised status; *Including 6 patients with both Mucorales and Aspergillus Univariate analysis of the study groups' main characteristics Conclusion Despite less aggressive surgical intervention for cranial involvement, OCFI patients treated with azoles had a higher survival rate, suggesting we may improve morbidity with a more conservative surgical approach in conjunction with azole treatment. The same trend is emerging for orbital involvement. Surgery for rhino-orbital-cerebral mycosis patients. Disclosures Sharon C. Chen, PhD MBBS, F2G PTy LTd: Advisor/Consultant|F2G PTy LTd: Grant/Research Support

Recurrent Endometriotic Cyst with High Ca-125 Level Mimicking Malignancy

Gynecologists who treat endometriosis, a chronic, disabling disease, face difficulties diagnosing and treating the condition. Endometriotic cyst, with internal septations and opacities sonologically, mimics malignancy. Increased levels of CA 125 Are used as a tumor marker in epithelial ovarian malignancies. It is also an important prognostic indicator and follow-up tool in managing ovarian malignancies. A moderate increase in CA125 levels is observed in physiological conditions like ovulation and benign conditions like endometriosis and PID. We present here a case of extremely elevated serum CA 125 level in a patient who presented with recurrent ovarian endometriosis. Mrs. X, 46 years old, presented with a complex ovarian cyst with CA 125 level- 1021 iu/ml. With a history of laparotomy for endometriotic cysts in the past. Intraoperatively bilateral complex ovarian cysts were identified, which were densely adherent to the lateral pelvic wall and rectum posteriorly. The ovarian cysts were excised with a hysterectomy. The Patient developed dribbling of urine on the third postoperative day. CT urogram revealed a right ureterovaginal fistula. Laparotomy done. Uretero ureteral anastomosis done by a urologist. The Postoperative patient remained dry. Histopathological evaluation revealed benign endometriosis. Extensive and aggressive surgeries are usually done for ovarian malignancies to provide optimal reduction. However, in our patient, risk assessment for malignancy based on radiological factors and tumor markers was highly suggestive of malignancy. Yet, the histopathology turned out to be benign endometriosis. Therefore, to avoid invasive investigations and surgeries associated with high morbidity, emphasis must be made on the possibility of raised CA 125 levels in benign conditions such as endometriosis.

Long-Term Survival Analysis of Pleural Mesothelioma Patients Undergoing Surgery: Brief Report From a Tertiary Referral Centre

Objectivesto date, no consensus has been reached on the surgical gold-standard in pleural mesothelioma (PM). We retrospectively reviewed our experience as a tertiary referral centre, to compare short- and long-term survival of PM patients undergoing different types of surgery. Methodsin retrospective, observational, single-centre study, we analysed all the patients histologically diagnosed with PM undergoing surgical procedures with palliative or curative intent at IRCCS Istituto Nazionale dei Tumori of Milan, Italy, from January 2003 to December 2020. The primary study endpoint was 10-year overall survival (OS) in three different types of resections: extra-pleural-pneumonectomy (EPP), pleurectomy/decortication (P/D), partial-pleurectomy/pleural-biopsy (PP/B). Secondary endpoints were postoperative hospital stay and postoperative 30-day and 90-day mortality rates. The survival function was estimated using Kaplan-Meier, and the Log-rank test was used for testing differences. Univariable and Multivariable Cox regression models were implemented to estimate Hazard Ratio (HR) for all variables of interest. Results243 consecutive patients were enrolled, EPP was performed in 49 (20.2%), P/D in 58 (23.8%), PP/B in 136 (56.0%) patients. The median follow-up time was 19.8 months. 10-year OS was significantly better for P/D group (16%, Log-Rank test p<0.0001) compared to PP/B (1.8%) and EPP (0%). No statistically significant differences were found among the 3 surgical groups in 30- and 90-day mortality rates. At multivariable analysis, gender (male, HR=1.58), type of resection (P/D, HR=0.55) and surgery date (recent years, HR=0.61) were found to be independent prognostic factors for OS. Conclusionsin PM, lung-sparing curative approach (e.g. P/D) should be preferred in highly selected patients and in highly experienced centres, whenever appropriate. Anyway, when P/D is not indicated, adopting palliative/conservative management (e.g. PP/B) could ensure comparable results as extremely aggressive surgeries (e.g. EPP). The aim of surgery in PM should not be reaching complete resection, but rather accomplishing significant resection allowing to complete the multimodality treatment in highly selected patients in experienced centers.

Role of aggressive locoregional surgery in treatment strategies for ipsilateral supraclavicular lymph node metastasis of breast cancer: a real-world cohort study.

Background: Breast cancer patients with synchronous ipsilateral supraclavicular lymph node metastases (ISLNM) have unfavorable prognoses. The role of supraclavicular lymph node dissection (SLND) as a surgical intervention in the treatment of this condition remains controversial. In this study, we aimed to evaluate the prognostic factors associated with breast cancer with ISLNM and to assess the potential impact of aggressive locoregional surgical management on patient outcomes. Methods: We conducted a retrospective analysis of 250 breast cancer patients with ISLNM who were treated with curative intent at our institution between 2000 and 2020. The cohort was stratified into groups based on the extent of axillary surgery. The first group, comprising 185 patients, underwent level I/II axillary dissection. The second group, consisting of 65 patients, underwent aggressive locoregional surgery, including levels I/II/III (infraclavicular) dissection in 37 patients and levels I/II/III + SLND in 28 patients. Our study evaluated overall survival (OS) and disease-free survival (DFS) as primary endpoints, and locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS) as secondary endpoints. Results: The median follow-up time among all patients was 5.92years (1.05-15.36years). The 5-year OS rate was 71.89%, while the DFS rate, LRRFS rate, and DMFS rates were 59.25%, 66.38%, and 64.98%, respectively. A significant difference in OS, DFS, LRRFS, and DMFS was observed between the second group and the first group (p < 0.01). No beneficial impact on recurrence, metastasis, or survival outcomes was observed in the levels I/II/III + SLND group compared to the levels I/II/III dissection group. Multivariate logistic regression analysis revealed that levels I/II/III ± SLND surgery and T stage were associated with OS (p = 0.006 and p = 0.026), while levels I/II/III ± SLND surgery, ER+/HER2-, and histologic grade were associated with DFS (p = 0.032, p = 0.001, p = 0.032). Conclusion: Breast cancer with ISLNM may be considered a locoregional disease, requiring a combination of systemic and local therapies. Aggressive locoregional surgery has been shown to positively impact recurrence, metastasis, and survival outcomes. This approach may provide improved management of the ISLNM for breast cancer patients.

Gastric-type adenocarcinoma of the endocervix: Potentially overcoming resistant behavior with surgery

ObjectiveGastric-type adenocarcinoma of the endocervix (GAS) is a rare form of human papillomavirus-independent cervical cancer commonly described as an insidious disease bearing a poor prognosis. Based on scarce data, uncertainty persists pertaining to its oncologic management. MethodFourteen cases of well-differentiated GAS treated at our institution from 2010 to 2021 were reviewed. Clinical characteristics, diagnostic tests results and oncologic outcomes were recorded and analyzed. Kaplan-Meier curves and log rank test were performed to compare survival curves between patients with tumors confined to the cervix (group 1: up to stage IB3) versus locally advanced or metastatic (group 2: stages II to IV). ResultsCervical cytologies and biopsies yielded low detection rates (38 and 42% respectively) leading to 87% of patients with locally advanced or metastatic disease at diagnosis. Median overall survival (OS) was 40.0 ± 15.9 months with a clear dichotomy in survival when comparing patients with disease confined to the cervix to those with higher stages (respectively 59.0 vs 12.0 months, p = 0.047). None of the 5 patients initially managed with concurrent chemoradiotherapy (CCRT) responded to treatment but fortunately 3 of the latter achieved remission after surgery. ConclusionWell-differentiated GAS did not show favorable response to chemotherapy and radiation. Surgical resection seems to be a cornerstone in the management of this disease, as all patients who achieved remission were treated with surgery, either upfront or after suboptimal response to CCRT. We suggest considering aggressive upfront surgery when feasible. If CCRT is selected to avoid upfront exenterative procedures, rapid evaluation of tumor response is recommended.

Preliminary Results of Preoperative Planning Using 3D Printing and Augmented Reality in Cryotherapy Treatment of Giant Cell Tumor of Bone-CRIO2AR Project.

Giant Cell Tumor of Bone is a benign tumor with high local aggressive expansion, which, in rare cases, spreads metastasis. Surgical treatment, which often consists of wide curettage to reduce recurrence risk, can lower the quality of life for those affected. Along with aggressive surgery, adjuvant intraoperative techniques have been implemented such as PMMA and cryotherapy. One of the most widely used cryotherapy techniques involves the use of probes to generate ice balls, which have been scientifically shown to have various impacts on the tumor. Although this has been acknowledged, no one has yet tested a way to accurately plan the positioning of cryotherapy probes before surgery, according to the research conducted by the authors. CRIO2AR is a randomized clinical prospective ongoing study by which it will be experimented via preoperative planning of ice probes placement using AR and 3D printing technologies. By studying a single clinical case with these technologies, the surgeon gains better awareness of patient's anatomy and tumor localization. Preliminary results are shown in the article. The first results are confirming that these technologies are applicable in clinical practice. Secondly, preoperative planning is proving to be reliable, easily replicable, and useful for the surgeon.

Lymph node dissection results, surgical management modalities and oncologic results of intrahepatic cholangiocarcinomas, single center experience

Background and Aims: Intrahepatic cholangiocarcinoma is a cancer of the biliary tract. The only current curative treatment for intrahepatic cholangiocarcinoma is liver resection. The aim of this study is given the result of the lymph node dissection, surgical management and recurrens ratio of intrahepatic cholangiocarcinomas in our center. Material and Methods: The medical record of patients who were treated for intrahepatic cholangiocarcinoma in our clinic were retrospectively evaluated between January 2019 to January 2023. Results: Twenty four patients were operated in our clinic. Of the patients, 12 were female, 12 were male, and the mean age was 52.75 ± 10.20 years. The median tumor size was 8.50 cm. Twelve patients had right hepatectomy, 6 patients had left hepatectomy, 2 patients had extended left hepatectomy, 2 patients had central hepatectomy and 2 patients had segment 4 plus 5 resection in the operation. The mean number of lymph node removed was 9.95 ± 3.56. Malignant lymph node was seen in 5 patients. Postoperative median hospital stay was 13.50 days. Mortality was observed in only 2 patient in the first 3 months postoperatively. The median overall survival of the patients was 318.50 days. Conclusions: As a result of our study, in patients with intrahepatic cholangiocarcinoma, patients who will be selected with preoperative correct staging, aggressive surgery by evaluating the comorbidities and conditions of patients with resectable tumors, removal of hepatoduodenal lymph nodes during surgery, and liver volume expansion procedures in patients who may develop remnant liver volume failure, to force to resection, which is the only curative chance of patients is demonstrated that it is necessary.

1231 Radical Vulvectomy and Reconstruction for Severe, Refractory Crohn's Disease of the Vulva: A Case Report

Abstract Vulval Crohn’s disease (VCD) is rare and can arise from direct infiltration, through fistulae or as non-contiguous lesions, so called metastatic disease. We present a case of a 32-year-old female with severe, refractory vulval Crohn’s disease (VCD), requiring radical vulvectomy and reconstruction. She had a subtotal colectomy for Crohn’s disease 8 years previously, and for one year had experienced vulval swelling and pain associated with perianal fistulae for which she underwent an abdomino-perineal resection. Though she achieved long term remission of her gastrointestinal disease, she continued to experience severe vulval symptoms with recurrent infections and abscesses despite treatment with immunomodulators and biologics over a period of 10 years. She then underwent a radical vulvectomy with bilateral gluteal fold flap reconstruction and skin grafting. She made an uncomplicated post-operative recovery. Histopathology showed active non-caseating granulomatous vulvitis. At 1 year follow up, there were no further disease flares, with significant improvement of her pain. Further plastic surgery is being considered. Our case demonstrates the value of surgical management in refractory VCD to improve symptoms, function and quality of life. Though medical therapy with immunosuppressive agents is recommended as first-line treatment, the course of VCD is unpredictable and often relapses on treatment cessation. VCD may persist for long after remission of gastrointestinal disease and may require more aggressive surgery using a multispecialty approach even in the context of active infective disease.

Radioguided Surgery for the Localisation of Specific Adenopathies in the Head and Neck Area.

Intraoperative identification and excision of specific lymphadenopathies is not always easy; it is, therefore, important to have complementary techniques that help us in the identification of these structures intraoperatively. The aim of this study is to present preliminary results of the use of ROLL technique (radioguided occult lesion localisation) as a method of excisional biopsy in the head and neck territory. We present 10 cases of patients with difficult to localise lymphadenopathies in the head and neck territory that underwent the ROLL technique. The radiotracer was only injected in the nodes that we wanted to study; in this way, all of them were correctly identified and extracted without resecting those that had no signs of pathology avoiding removing healthy lymphatic tissue and reducing morbidity. The ROLL technique is a useful technique, since in all of the patients, the previously marked adenopathy was accurately identified and excised; we reduced the intraoperative time and avoided the complications derived from more aggressive cervical exploratory surgeries.

A Fully Automated Post-Surgical Brain Tumor Segmentation Model for Radiation Treatment Planning and Longitudinal Tracking.

Glioblastoma (GBM) has a poor survival rate even with aggressive surgery, concomitant radiation therapy (RT), and adjuvant chemotherapy. Standard-of-care RT involves irradiating a lower dose to the hyperintense lesion in T2-weighted fluid-attenuated inversion recovery MRI (T2w/FLAIR) and a higher dose to the enhancing tumor on contrast-enhanced, T1-weighted MRI (CE-T1w). While there have been several attempts to segment pre-surgical brain tumors, there have been minimal efforts to segment post-surgical tumors, which are complicated by a resection cavity and postoperative blood products, and tools are needed to assist physicians in generating treatment contours and assessing treated patients on follow up. This report is one of the first to train and test multiple deep learning models for the purpose of post-surgical brain tumor segmentation for RT planning and longitudinal tracking. Post-surgical FLAIR and CE-T1w MRIs, as well as their corresponding RT targets (GTV1 and GTV2, respectively) from 225 GBM patients treated with standard RT were trained on multiple deep learning models including: Unet, ResUnet, Swin-Unet, 3D Unet, and Swin-UNETR. These models were tested on an independent dataset of 30 GBM patients with the Dice metric used to evaluate segmentation accuracy. Finally, the best-performing segmentation model was integrated into our longitudinal tracking web application to assign automated structured reporting scores using change in percent cutoffs of lesion volume. The 3D Unet was our best-performing model with mean Dice scores of 0.72 for GTV1 and 0.73 for GTV2 with a standard deviation of 0.17 for both in the test dataset. We have successfully developed a lightweight post-surgical segmentation model for RT planning and longitudinal tracking.

Vagal electrostimulation in postoperative thoracic surgery reduces the systemic inflammatory response and cardiopulmonary complications: an experimental study in pigs.

Conventional thoracotomy (CT) often leads to systemic inflammatory response syndrome (SIRS), which induces several clinical complications. CT remains widely used in low-income institutions. Although minimally invasive surgical procedures, such as robotic surgery (RS), have been used to prevent many of the complications inherit from the surgical procedure. Here, we investigated the protective effect of vagus nerve stimulation (VNS) in a pre-clinical model during CT or RS and postoperative period (POP) relative to clinical complications and inflammatory control. The objective was to compare hemodynamic features and cytokine levels in the blood, lung, and bronchoalveolar lavage (BAL) fluids of animals subjected to CT or RS with or without VNS. Twenty-four minipigs were subjected to 12 animals CT and 12 animals RS, with or without VNS, and accompanied 24 h later by pulmonary lobectomy. Blood samples for evaluating the hemodynamic parameters were collected before the surgical preparation, immediately after the beginning of VNS, and every 4 h until 24 h after the lobectomy. BAL fluid and lung tissue were collected at the end of the experiment. Cytokine levels were evaluated in the blood, BAL fluid, and lung tissues. VNS maintained a more stable heart rate during POP and decreased the incidence of overall cardiac complications while preventing increase in IL-6 levels 12 h after lobectomy, compared to sham animals. No differences were found in cytokine expression in the BAL fluid and lung tissue in any of the studied groups. Taken together, our data suggested that VNS should be considered a non-pharmacological tool in the prevention of the exacerbated inflammatory response responsible for severe clinical complications, especially in more aggressive surgical procedures.